When is a programmed follow-up meaningful and how should it be done? Professor Alastair Watson University of Liverpool

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1 When is a programmed follow-up meaningful and how should it be done? Professor Alastair Watson University of Liverpool

2 Adenomas/Carcinoma Sequence Providing Time for Screening Normal 5-20 yrs 5-15 yrs ADENOMA Mild Moderate Severe Cancer Prevalence in 50 yr olds 25% 6% 0.25%

3 Only early cancers can be cured 5 yr survival 100% 90% 65% 25% 15% Proportion 11% 33% 33% 23%

4 Removing polyps reduces incidence of colorectal cancer Winawer et al. NEJM 1993;329:1977

5 Surveillance after polypectomy 30 50% of patients have adenomas 5 years after initial polypectomy - Development of new lesions - Lesions missed at initial colonoscopy

6 Factors that influence recurrence of adenomas Size > 10mm Multiplicity 3 Histology Villous, high grade dysplasia Previous cancer

7 Factors that influence recurrence of Baseline finding adenomas % with advanced neoplasia at 5.5yr Relative Risk No adenoma 2.4% Adenoma <10mm 6.1% adenoma <10mm 11.9% Adenoma >10mm 15.5% Villous adenoma 16.1% High grade dysplasia 17.4% Cancer 34.8% CI Advanced neoplasia = tubular adenoma 10 mm, adenoma with villous histology or high-grade dysplasia, or invasive cancer. Lieberman et al. Gastroenterology 2007;

8 Guidelines for follow-up: Low Risk Low risk Guideline Society Initial interval Subsequent interval if follow-up colonoscopy shows only low-risk adenomas Subsequent interval if follow-up colonoscopy shows no adenomas 1-2 small (<1cm) adenomas Task force 5-10 years 5-10 years Not specified ACG 5 years Not specified 5 years ASGE No earlier than 5 years BSG 5 years or no surveillance* No earlier than 5 years 5 years or no surveillance Task force = Multi-Society Task Force on Colorectal Cancer ACG = American College of Gastroenterology ASGE = American Society of Gastrointestinal Endoscopy BSG = British Society of Gastroenterology * Would be included in national screening programme No earlier than 5 years No surveillance From Lin et al. 2007;370:

9 Guidelines for follow-up: Intermediate Risk Intermediate risk Advanced neoplasm or 3-10 small adenomas Guideline Society Initial interval Subsequent interval if follow-up colonoscopy shows only low-risk adenomas Task force 3 years 5 years 5 years ACG 3 years Not specified 5 years Subsequent interval if follow-up colonoscopy shows no adenomas ASGE 3 years Not specified No earlier than 5 years BSG 3 years 3 years 3 years Task force = Multi-Society Task Force on Colorectal Cancer ACG = American College of Gastroenterology ASGE = American Society of Gastrointestinal Endoscopy BSG = British Society of Gastroenterology From Lin et al. 2007;370:

10 Guidelines for follow-up: High Risk High Risk Guideline Society Initial interval Subsequent interval if follow-up colonoscopy shows only low-risk adenomas Subsequent interval if follow-up colonoscopy shows no adenomas >10 small adenomas Task force < 3 years Not specified Not specified ACG Not specified Not specified Not specified ASGE < 3years Not specified 5 years BSG 1 year** 3 years 3 years Task force = Multi-Society Task Force on Colorectal Cancer ACG = American College of Gastroenterology ASGE = American Society of Gastrointestinal Endoscopy BSG = British Society of Gastroenterology From Lin et al. 2007;370:

11 Guidelines for follow-up: High Risk High Risk Guideline Society Initial interval Subsequent interval if follow-up colonoscopy shows only low-risk adenomas Subsequent interval if follow-up colonoscopy shows no adenomas Large sessile adenoma Task force 2-6 months Customised Customised ACG 3-6 months Not specified Not specified ASGE 2-6 months Customised Customised BSG 3 months Customised 1 year Task force = Multi-Society Task Force on Colorectal Cancer ACG = American College of Gastroenterology ASGE = American Society of Gastrointestinal Endoscopy BSG = British Society of Gastroenterology From Lin et al. 2007;370:

12 Quality of colonoscopy is crucial Incomplete removal at initial endoscopy Miss rate for adenomas >1cm is up to 12% Withdrawal time must be > 6 min Quality of bowel preparation must be high

13 Colonoscopy Complications Author No of colonoscopies Bleeding (%) Perforation (%) Mortality (%) Bowles Eckardt Jentschura Sieg Waye Wexner Nelson

14 Estimated deaths caused by colorectal cancer screening USA figures No screening FOBT FS FOBT+FS Colo CRC deaths 57,904 28,933 29,173 24,194 23,014 Deaths from colonoscopy complications Figures assumes a colonoscopy mortality rate of 0.01% Deaths caused by screening tend to be of individuals who are not destined to die of colorectal cancer Ladabaum & Song Gastroenterology 2006;129:1151

15 The Costs of Screening USA figures $=Billions/year No screening FOBT FS FOBT+FS Colo CRC care $8 $4.9 $4.5 $3.9 $3.6 Testing $0.4 $4.2 $5.7 $7.1 $7.4 Testing complications $0.01 $0.1 $0.1 $0.14 $0.21 Total $8.4 $9.2 $10.3 $11.2 $11.2 Although costs of treating colorectal cancer fall with screening, the total costs including screening are higher Ladabaum & Song Gastroenterology 2006;129:1151

16 Chromoendoscopy & narrow band imaging aids detection of flat adenomas Chromoendoscopy Narrow band imaging

17 Virtual Colonscopy

18 Surveillance after surgical resection Objectives To identify recurrences when further surgery is likely to be curative To identify second cancers Psychological support

19 The majority of clinical studies favour intensive follow-up Intensive follow-up will include: Regular colonoscopy CT scanning CEA Blood count Renehan et al BMJ 2004;328:81

20 Intensive post-surgical surveillance No. of years gained years over 5 years Cost for each life year gained = 3400 Renehan et al BMJ 2004;328:81

21 Follow-up methods 5 year survival after resection of isolated hepatic metastases: 25 40% History and examination CEA CT scanning MR scanning Detects 6% of recurrences Poor sensitivity and specificity High sensitivity and specificity High sensitivity and specificity

22 Endoscopic surveillance American Cancer Society Guidelines Incidence of metachronous cancers 3 7% 1 metachronous tumour for every 157 colonoscopies Colonoscopy 3 6 months after resection Colonoscopy at 1 year, if normal then 3 yearly Sigmoidoscopy for low anterior resections 3-6 monthly

23 Conclusions Intensive surveillance after surgery increases survival Should be offered to patients with stage II or III disease Should include colonoscopy and CT or MR scanning Screening after polypectomy is costeffective A high standard of colonoscopy is essential AND

24 Take the colonoscope out SLOWLY!

25 Acknowledgements Paul Collins Nadeem Sarwar

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